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Summers, E.M., Morris, R.C., Bhutani, G.E., Rao, A.S., & Clarke, J.C. (2020). A survey of psychological practitioner workplace well-being. Clinical Psychology and Psychotherapy. Online first publication: https://doi.org/10.1002/cpp.2509

Burnout is a specific form of workplace psychological stress characterized by emotional exhaustion (loss of energy), depersonalization (cynicism towards patients), and lack of personal accomplishment (dissatisfaction). Research has shown higher than average levels of burnout in psychological practitioners. The National Health Service (NHS) in the United Kingdom (UK) employs a large workforce of psychological practitioners (psychologists, counsellors, assistant psychologists, social workers, and others) to provide mental health care. In surveys among UK practitioners, 48% felt depressed, almost 50% felt like a failure, and 92% felt that their job was stressful. Unfortunately, many providers tend not to seek help when they feel burned out, anxious, or depressed. Summers and colleagues conducted a large-scale survey of psychological practitioners that provide mental health care in the UK’s NHS system. Over 1,600 practitioners responded to questionnaires about professional and personal well-being, and about workplace conditions. Results showed a high correlation (r = .61) between workplace well-being and general personal well-being, suggesting that experiences in the workplace affect experiences outside of the workplace and vice versa. Scores of professional and general well-being were significantly below the national average, indicating poorer well-being among psychological providers compared to the general population. There were no differences among genders, and among most ethnic groups, and higher pay was not associated with higher well-being. Noteworthy factors that correlated with poorer professional well-being included workplace harassment/bullying by managers, feeling depressed, and having a physical disability. Being on contract with the NHS, working only part-time for the NHS, or working in private practice were each related to somewhat better well-being.

Practice Implications

There is ongoing concern about professional well-being and burnout among psychological practitioners as suggested by international surveys. Many NHS employees in the UK and mental health professionals around the world report high levels of burnout. Protective factors for psychological practitioners might include: having more control over one’s work, a supportive organizational culture, and taking care of one’s own psychological and physical health. Personal therapy, peer supervision, and consultation may be means by which therapists manage emerging dissatisfaction and depersonalization that may affect their work with patients and their own well-being.

Gloster, A. T., Rinner, M. T., Ioannou, M., Villanueva, J., Block, V. J., Ferrari, G., ... & Karekla, M. (2020). Treating treatment non-responders: A meta-analysis of randomized controlled psychotherapy trials. Clinical Psychology Review, 75, https://doi.org/10.1016/j.cpr.2019.101810.

Generally, there are a number of effective treatments for mental disorders including psychotherapy and medications. However, by some estimates, about 40% of patients with mood or anxiety disorders do not respond to these treatments. Research shows that patients who do not respond to initial treatments tend to have lower quality of life and higher mortality. By definition, treatment non-response indicates a failure of the treatment to achieve symptom reduction for patients. There is a research literature looking at the impact of introducing a subsequent treatment like psychotherapy for patients who do not respond to a previous treatment (most often a medication). In this meta-analysis Gloster and colleagues examined the efficacy of adding psychotherapy for patients who were not responsive to a previous treatment. They only included randomized controlled trials of patients diagnosed with mood or anxiety disorders. The authors found 18 studies of this kind that had 1734 participants. Most of the studies (80%) used medications as an initial treatment. The psychotherapies that were given to non-responders were quite varied including CBT, psychodynamic therapies, and DBT. The authors adjusted effect sizes downward for publication bias – or the estimated effects of negative studies that were not published. Even with that downward adjustment, adding psychotherapy after previous treatment non-response resulted in significant positive effect for patients in terms of reduced symptoms (SMD = 0.45; 95% CI: 0.16, 0.75). Similar findings were noted for quality of life. However, there was a lot of variability in effects across studies. Better outcomes were not associated with a particular diagnosis or treatment type. The positive effects remained significant at follow up, but they did not hold up after adjusting for publication bias (SMD = 0.359; 95% CI -0.349, 1.068, p > .05).

Practice Implications

The findings of this meta-analysis are promising for using psychotherapy for those who do not respond to initial treatment, mostly with medication. Both symptoms and quality of life improved moderately with a second round of treatment. This is notable because treatment non-responders may experience frustration and demoralization, and these patients tend to have chronic conditions that cause significant impairment. An important caveat is that the evidence for longer term improvements may not be reliable, and so it is not clear whether the positive effects are sustained. Offering a patient a re-start of treatment may help them to establish new hope for recovery if the subsequent treatment is framed as something different from the previous interventions that did not work for them.

Weisel, K.K., Fuhrmann, L.M., Berking, M., Baumeister, H., Cuijpers, P., & Ebert, D.D. (2019). Stand alone smartphone apps for mental health: A systematic review and meta-analysis. NPJ Digital Medicine, 2, 118. https://doi.org/10.1038/s41746-019-0188-8

Mental health and lifestyle apps are very popular. There are more than 318,000 health related mobile apps on the market, 490 of which are specifically about mental health. Most of the apps do not provide information about their effectiveness, and only 11% appear valid on the face of it. Apps are potentially useful to increase access to mental health treatments since smartphones are ubiquitous in the population. However, past reports show that the drop-out rates of unguided internet interventions for mental health are very high, only 17% of clients actually complete all the modules, the average client only completes about 16% to 25% of modules, and any positive effects often disappeared when assessed in the longer term. In this meta-analysis, Weisel and colleagues assess if standalone psychological interventions delivered by smartphone apps are efficacious for mental disorders. Their systematic review found 19 randomized controlled trials that directly compared a smartphone app to a control group (e.g., no treatment) for a variety of disorders (depression, anxiety, PTSD, sleep problems, substance use, suicidal behavior). Almost half of the interventions were CBT-based. Only 1 of the 19 studies had a low risk of bias – that is only 5% of studies were high quality in terms of sampling, randomization, data analysis, and so on. More than half of studies were very low quality. The pooled effect size from six comparisons for depression showed a positive effect of smartphone apps at post-treatment to reduce depressive symptoms (g = 0.33; 95% CI: 0.10–0.57, p = .005). Similar positive findings were found for smoking cessation. These effects are considered small by most standards. However, the findings from four comparisons for anxiety disorders were not significant (g = 0.30, 95% CI: −0.1 to 0.7, p = 0.145). Similar non-significant results were found for most other disorders as well. There were not enough studies to assess the longer-term effects of apps beyond immediately post-treatment.

Practice Implications

The main problem with this research area is that the quality of the studies generally is very low. Researchers have known for some time that lower quality studies tend to result in inflated treatment effects. So even if the meta-analysis found small significant effects of mental health apps for depression and smoking cessation, these findings are not likely reliable. Further, there is almost no research on the longer-term outcomes to assess if any positive effects are lasting. The research does not support the use of apps and computerized interventions as standalone treatments. They may be useful as an adjunct to traditional therapy or when they are provided with sufficient guidance by a therapist.

Markowitz, J.C., Milrod B., Heckman, T.G., Bergman, M., Amsalem, D., Zalman, H., Ballas, T., Neria, Y. (2020). Psychotherapy at a distance. American Journal of Psychiatry, doi: 10.1176/appi.ajp.2020.20050557.

Teletherapy was once seen as an adjunctive therapy mainly reserved for patients who lived in remote locations and who could not otherwise access psychotherapy. Now, due to public health restrictions related to COVID-19, teletherapy has become standard care. Conscientious psychotherapists who want to practice based on the best available evidence have looked to the research for some guidance. Previous PPRNet Blogs (see the May, June, and July 2020 Blogs at www.pprnet.ca) have highlighted some of the research related to teletherapy and videoconferencing psychotherapy. In this meta-review, Markowitz and colleagues in part assess the quality of some of these findings, that is – how good is this research. Quality of research often hinges on a number of factors: is the sample size large enough to make solid conclusions, are the methods used appropriate and robust (like randomized controlled trials), is there a sufficient quantity of research that can be summarized, and are patient samples in the studies similar to those typically see in clinical practice. There are thousands of studies of face to face psychotherapy for depression, but by comparison the number of studies of teletherapy are relatively sparse. Many studies of teletherapy are not randomized controlled trials in the typical sense, but rather they are a hodgepodge of studies of different interventions, patients, settings, and outcomes. Nevertheless, the outcomes are generally encouraging in terms of the efficacy of teletherapy. In a recent meta analysis, effects of videoconferenced psychotherapy appear to be equivalent to face to face therapy, but there were only 11 studies in all, only 5 of the studies were considered high quality, and 4 of the high quality studies were with military veterans with PTSD in the Veterans Administration System in the US. Regarding specific orientations, Markowitz and colleagues reported three rigorous trials showing CBT or interpersonal psychotherapy reduced depressive symptoms. There are six randomized trials of group therapy by videoconferencing or telephone, but most are of low quality and often specifically focused on patients with HIV.

Practice Implications

Videoconferenced and telephone delivered psychotherapy are likely here to stay in some form, even after the COVID-19 pandemic. Teletherapy greatly expands access for some, though some patients including homeless, poorer, or the elderly individuals still may not have adequate access. The research evidence for the efficacy of remote therapy is encouraging, but also problematic. Most research trials are too small to draw meaningful conclusions, and few studies focus on therapeutic factors. Anecdotal reports suggest that those who are socially anxious or avoidant may prefer remote care, however it is also possible that teletherapy may exacerbate problematic avoidance behaviors among some patients. At the moment, the research lags far behind the rapid transition to remote care that has occurred in the past months.

Simpson, S., Richardson, L., Pietrabissa, G., Castelnuovo, G., Reid, C. (2020). Videotherapy and therapeutic alliance in the age of COVID-19. Clinical Psychology and Psychotherapy, https://doi.org/10.1002/cpp.2521

The therapeutic alliance is one of the most robust predictors of patient outcomes in psychotherapy. The alliance refers to the patient’s and therapist’s agreement on the goals of therapy (what the patient wants for an outcome), the tasks of therapy (what to do in therapy to achieve these goals), and the relational bond between the patient and therapist. Despite the importance of the therapeutic alliance, psychotherapists tend to rate it lower in videoconferenced psychotherapy compared to face to face therapy. That is, psychotherapists are skeptical that one can develop and maintain the same quality of alliance in videoconferenced psychotherapy compared to face to face therapy. In this review, Simpson and colleagues evaluate the research on the alliance in videoconferenced psychotherapy. The authors argue that videoconference psychotherapy provides greater access for some patients, and also creates therapeutic opportunities that are not possible in face to face therapy. For example, those with PTSD, agoraphobia, social avoidance, and severe anxiety may find engaging in videoconferenced psychotherapy to be easier. Younger individuals who feel more at home with social interactions on a video screen may also engage better with videoconferenced psychotherapy. Simpson and colleagues reviewed 24 studies that examined the therapeutic alliance in the context of video therapy. There was a wide range of technologies and clinical groups, thus making meaningful comparisons difficult. Generally, both clients and therapists rated the alliance highly. There is some evidence that for a few patients, like those concerned with privacy and stigma, videoconferenced psychotherapy may be less threatening. However, it must be noted that most of these studies were surveys, analogue studies not including real therapeutic contexts, or single case reports. Currently, there appears to be no high quality randomized controlled trial comparing videoconferenced versus face to face therapy on the quality of the alliance.

Practice Implications

As is the case with treatment efficacy studies, high quality trials looking at the therapeutic alliance in videoconferenced psychotherapy lag far behind practice. As a result, the research provides little guidance to therapists. Small studies and anecdotal reports suggest that the alliance may be as good in videoconferenced psychotherapy as in face to face therapy, and that some patient, especially those with high levels of avoidance and anxiety, may find videotherapy to be less threatening. Given the ubiquitous nature of technology, and the likelihood that videoconferenced psychotherapy will continue well into the future, it is important that researchers turn to examining what works in videotherapy and for whom.

Peluso, P. R., & Freund, R. R. (2018). Therapist and client emotional expression and psychotherapy outcomes: A meta-analysis. Psychotherapy, 55(4), 461–472.

Emotions and emotional experiences are key to being human, and therefore are key to psychotherapy processes and outcomes. Emotion-focused therapy, for example, emphasizing helping clients to overcome their avoidance of emotions by exploring emotions in therapy in order to achieve change. Nevertheless, many therapeutic orientations focus on emotional expression, avoidance of emotions, emotional experiences, and understanding emotions as a means of helping clients to change and to have a better existence. Therapists of all stripes tend to work at creating a therapeutic context so that patients can have a corrective emotional experience. Primary emotions are universal and include happiness, sadness, fear, surprise, disgust, and anger. Secondary emotions are influenced by context and include embarrassment, guilt, and pride. All emotions and their experiences are influenced by cultural contexts, attitudes, and rules. A key aspect of psychotherapy includes helping clients to organize or make meaning of their emotions, and such therapeutic work is associated with positive client outcomes. In this meta-analysis, Peluso and colleagues evaluated the research on therapist and client emotional expression in psychotherapy, and its relationship to client outcomes. Thirteen studies found the effects of therapists’ expression of affect during therapy on client outcomes after the end of therapy had a mean effect size of r = .28 (95% CI: .17, .35), which was statistically significant and moderately large. The 42 studies that looked at client expression of affect during therapy and how it related to client outcomes after therapy found an average effect size of r = .40 (95% CI: .32, .48), which was also statistically significant moderately large.

Practice Implications

This meta analysis emphasizes that emotions matter in psychotherapy. The capacity of therapists to judiciously express emotions, and to help clients to experience and make meaning of their emotions is an important therapeutic skill. Therapists need to focus on and validate clients’ emotions, and therapists should encourage clients to understand and process (i.e., make meaning of) their emotions. This work must occur in the context of a safe, trusting therapeutic relationship. Meaning making and emotional resolution should be considered as key therapeutic goals for most therapies.